1. Spinal Orthoses Objectives for application of orthosis
controlling the position of the spine
applying the corrective forces to abnormal curvatures
aiding in spinal stability
restricting spinal segment movement after acute trauma or after surgical procedure to protect against further injury
mechanical effect/sensory feedback

2. Spinal Orthoses
The function of rigid and flexible orthosis are the consequence of the forces that they apply on the body The location, magnitude and direction of these forces vary with the design of the orthosis ,tightness with which it is worn and the patients attempts to move against it As a result of force application nearly every spinal orthosis produce three effect 1)Increase intracavitary pressure 2)Restrict trunk motion 3)Modify skeletal alignment

4. Deformities of the Spine
Kyphosis - flexion
Lordosis - extension
Normal
cervical lordosis 20-40º
thoracic kyphosis 20-40º
lumbar lordosis 40-60º
Scoliosis - twisting (rotation) with hump formation, more common in females than males
usually first appears in late childhood/early teenage
causes :polio or other condition causing muscle imbalance
90% curve to the right, only 2% require treatment
unsightly

5. Spinal Orthoses
Based on the joints they encompass and analysis of their control motion the Spinal orthoses are divided into the following types:
1) CO: Cervical Orthoses
2)CTLSO: Cervical thoracic ,lumbosacral Orthoses
3)TLSO: thoracic ,lumbosacral Orthoses
4)LSO: lumbosacral Orthoses

6. Cervical Orthoses
These are used to restrict head and neck motion, and limit flexion,extension,rotation of the head and the cervical spine
The cervical orthoses are further divided into
1)Soft collar-for soft tissue injury, arthritic change
2) Hard collar
3)Philadelphia collar
4)SOMI
5)Post appliance
6)Custom molded
7)Halo type

7. Cervical Orthoses
Collar: A basic collar is a device that wraps around the neck and is adjustable circumferentially. It may have a provision for height adjustment ,be single or multiple layered as is of variable firmness. Materials used include resilient polyethylene, sponge rubber etc
Functions:1) It provides some mechanical restrain to flexion, extension,& (to a lesser degree) lateral flexion and rotation.
2)It reminds the wearer to limit head and neck motions

8. Types Of Collars
Soft collar: A soft collar is made of foam rubber covered with stockinette(An elastic knitted fabric used especially in making bandages) The soft collar will be used for patients who have pain in the neck due to strain or stress. It acts as a reminder for the patient to not flex his/her neck through a sensory feedback. It can be made to measure or pre-made with fasteners of lay-on Velcro at the posterior of the neck. In some cases the Velcro strap will be adjusted so that the patients cannot don or doff the collar themselves.

9. Types Of Collars
Hard Collar A hard collar provides a more effective way of controlling flexion and extension of the cervical vertebrae of the spine. It is made of padded polyethylene.

10. Types Of Collars
Philadelphia Collar A Philadelphia collar prefabricated of polyethylene foam reinforced with rigid anterior and posterior plastic strips, this device covers most of head and neck than the basic collars. The Philadelphia collar terminates superiorly over the mandible and it’s lower border is at the proximal thorax.
It easy to fit and adjust on the patient. It comes with different sizes and depths
In Philadelphia collar the motion restriction is increased by the reinforcing anterior and posterior strips, which also permit selective adjustment of head position

11. Post Appliance
Post Appliance: It has an anterior section consisting of a sternal plate ,1 or 2 anterior straps ,2 anterior uprights and a mandibular support as well as a posterior section consisting of a inter scapular plate ,1 or 2 posterior uprights and an occipital support.
The anterior and posterior straps are usually connected by straps between anterior and posterior support and by shoulder straps between the interscapular and sternal plates
Sternal plate
Madibular support

12. Post Appliance The uprights are adjustable for height.
The post appliance is commonly pre fabricated of aluminum ,with plastic or leather padding of parts that contact the body.
Functions: 1)It resist flexion and extension of the head and cervical spine by forces applied under the mandible. These forces also limit lateral flexion and rotation.
2) It permits selective positioning of the head by varying the length of the uprights.

13. Sterno-occipital mandibular immobilizer
Sterno-occipital mandibular immobilizer : It has a single anterior upright with attached mandibular support ,can be quickly and easily moved from sternal palte.This allows the patient to eat, wash while remaining in supine semi immobilized position. The posterior uprights arise from a sternal plate ,extend upwards and backwards and attach to the occipital support.
Anterior upright

14. Sterno-occipital mandibular immobilizer
Fixtures are available to enable the SOMI to attach to custom made spinal jacket ,thus increasing overall orthotic control of vertebral column.
Functions:1)It resist flexion and extension of the head and cervical spine by forces applied under the mandible. These forces also limit lateral flexion and rotation.(control if cervical extension and lateral flexion is significantly less as compared to post appliance.

15. Custom molded appliances
Custom molded appliances: Custom molded orthoses may be made of thermoplastic or leather formed over a modified plaster model of the patients skull and torso or of low temperature thermoplastic formed directly on the patient.
They are designed to restrict all neck motions also thoracic motion of varying degrees depending on the extend of their downward extension on the thorax
Those which extend distally beyond the upper thorax are classified as cervicothoracic devices ,while cuirass extend superiorly over the chin ,mandible .It may terminate just above the inferior angles of scapula or may continue further downwards to inferior coastal margin depending upon the type of control required.

16. Custom molded appliances
The Minerva type includes entire posterior skull and includes a band around the forehead ,extends downward to the inferior coastal margin. If better control is needed it may terminate in a pelvic girdle.
Cuirass type
Minerva type

17. Halo Cervical Orthoses
The Halo assembly provides the greatest control of all cervical orthosis .It’s basic components are a halo ring ,distraction rods ,shoulder bars, and a distal fixation component. The halo encircles the skull and is secured by fixation pins that penetrate the outer table of the skull. The upper and lower ends of the length adjustable distraction straps are attached respectively to the Halo and shoulder bars .The latter in turn are attached to distal fixation components ,which may be a vest, body jacket, pelvic girdle or cast.
Halo ring
Shoulder bars
Distraction bars
Jacket, vest

18. Lumbosacral orthoses The Lumbosacral orthoses are of two types:
1)Flexible:
The lumbosacral corset is made of fabric (cloth garment)that encompasses the torso with adjustable front ,side or back Velcro fasteners (hooks)allow user to control degree of tension for proper support and comfort.
It extends just below the xiphoid process to above the pubic symphysis.
If a prefabricated garment cannot be used then custom corsets may be fabricated based on the measurements of the individual patient

19. Lumbosacral orthoses
Functions: They support the lower spine, reduce pressure on the lumbar sacral region by increasing intra-abdominal pressure also acting as a reminder to the patient to maintain correct posture(restrict motion). This orthosis is very popular in the treatment of lower back pain.

20. Sacroiliac Belt
The sacroiliac belt encircles the pelvis between iliac crest and the greater trochanter. Perineal straps prevent upward displacement
Functions: The sacroiliac belt is used for patients with postpartum or traumatic separation of the sacroiliac or symphysis pubis.
The sacroiliac corset: is a cloth garment which encompasses the pelvis and is adjustable in circumference by means of side, front, back laces or hook
Functions: Although most effective in restraining motion this orthosis may assist in elevating intra-cavity pressure and may be useful for postpartum and posttraumatic stabilization of pelvis joint.

21. Three Point Pressure system
The three point pressure principle of an example of parallel force system used in brace design
The supporting force of the brace is arranged such that two forces pressing against the trunk or limb are opposed by a third force ,which is located between the other two.
F F2 F3

22. Three Point Pressure system
The single opposing force is equal in magnitude to the two forces acting in the same direction
F3=F1+F2
This three point pressure system is used for immobilization or support of the body part
E.g. 1)Spinal Bracing
2)Leg Bracing/Genu Valgum
3) Correction of foot deformity

23. Foot deformity
Genu Valgum

24. LSO Flexion Extension Control
This rigid orthosis consist of two posterior uprights attached inferiorly to a pelvic band and superiorly to a thoracic band. A full front abdominal support is fastened to the aluminum or plastic frame by means of straps.
In case of full front abdominal support and related straps a corset may be worn over the orthosis
The lateral end of the pelvic band may be located below the anterior superior iliac spines and should extend to midtrochanteric line to stabilize the orthosis

25. LSO Flexion Extension Control
Functions: This orthosis applies 2 3-point force systems .The first restricts trunk extension, increases intracavitary pressure, the second acts to restrict trunk flexion

26. LSO Flexion Extension Lateral Control
The addition of lateral uprights to the previously described lumbosacral orthosis provides a lumbosacral F-E-L orthosis. To avoid pressure on iliac crest the lateral uprights must be fitted carefully.
Functions: The functions of the lumbosacral F-E-L orthosis are identical to those F-E control LSO except for the degree of limitation of lateral trunk motion
Restrictions of these motions is more effective because the ends of pelvic and thoracic bands are anchored by lateral uprights

27. LSO Extension Lateral Control
This orthosis has pelvic and thoracic bands joined by lateral uprights that are pivotably attached to the thoracic band but not to the pelvic band. Two oblique lateral uprights are attached pivotably to the lateral uprights and rigidly to the pelvis band
Functions: It provides a single 3-point force system that limits trunk extension in the lumbar spine and also increases intracavity pressure. If the forces are of sufficient magnitude yet tolerable to the patient they will decrease lordosis

28. Thoracolumbosacral corset
The thoracolumbosacral corset is made of fabric (cloth garment)that encompasses the torso and the pelvis with adjustable front ,side or back Velcro fasteners (hooks) Posteriorly it’s superior border is at mid-capsular level .
Shoulder straps encircle the shoulder ,cross posteriorly and fasten anteriorly
The corset is usually reinforced with posterior rigid or semi rigid stays extending the full length of orthosis also it should fit all body contours smugly
Functions: used to restrict trunk motion.

29. Thoracolumbosacral orthoses
TLSO F-E control orthosis: This orthosis consist of 2 posterior uprights attached inferiorly to a pelvic band;
An interscapular band stabilizes the upright and serves as an attachment for auxiliary straps .
Anteriorly there may be a corset or a full front abdominal support or and related straps. the auxiliary straps which have superior ends of upper upright ,extend anterior over the shoulders and pass under the axillae to buckle at each end of the interscapular band
Also known as Taylor brace

30. TLSO Flexion Control
This orthosis consist of an anterior and a lateral torso frame to which are attached a sternal pad, a suprapubic pad,2 lateral pads, a thoracolumbar pad
Functions: A single 3-pt pressure s/m is provided that restricts forward flexion

31. TLSO F-E-L Control
This aluminum or plastic orthosis consist of plastic and thoracic bands connected to a pair of thoracolumbosacral posterior uprights and a pair of lateral uprights .A intrascapular band is fastened to the posterior uprights and serves as an attachment for auxillary straps. An abdominal support is laced to the lateral uprights
Functions: There is a greater tendency to limit rotation and lateral trunk motion in F-E-L control

32. TLSO F-E-R Control
This aluminum orthosis consist of pelvic and thoracic bands connected by two lateral uprights. An abdominal support is laced to the lateral uprights. The thoracic band extends anteriorly, superiorly and subcavicular pads are provided
Functions: the F-E-R provides 2 three pt force s/m’s 1)to limit trunk flexion in thoracic and upper lumbar spine 2)The other restricts trunk extension in lumbar spine

33. TLSO F-E-L-R Control
When maximum immobilization of the thoracic and lumbar spine are desired a custom-made plastic body jacket may be used. The design is quite effective in maintaining trunk alignment ,contact is essentially a jacket which may be made of thermoplastic material
Functions: A well fitted and essentially total contact jacket applies firm counterforces to restricts motion in all planes

34. Cervico-thoracic-lumbo-sacral orthosis
Milwaukee brace: used for scoliosis
consists of a rigid plastic pelvic girdle connected to a neck ring over the upper thorax by one anterior, broad aluminum bar and two posterior paraspinal bars.
The cervical ring has mandibular and occipital bars, which rest 20–30mm inferior to occiput and mandible
Pads strapped to the bars apply a transverse load to the ribs and spine to correct scoliotic curvatures
Indications:
Idiopathic or flexible congenital scoliosis